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Shoctor NA, Brady MP, McLeish KR, Lightman RR, Davis-Johnson L, Lynn C, Dubbaka A, Tandon S, Daniels MW, Rane MJ, Barati MT, Caster DJ, Powell DW. Increased Urine Excretion of Neutrophil Granule Cargo in Active Proliferative Lupus Nephritis. KIDNEY360 2024; 5:1154-1166. [PMID: 39207891 PMCID: PMC11371349 DOI: 10.34067/kid.0000000000000491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 06/10/2024] [Indexed: 09/04/2024]
Abstract
Key Points Neutrophil degranulation participates in glomerular injury in proliferative lupus nephritis. Urine excretion of neutrophil granule proteins is a potential diagnostic for proliferative lupus nephritis. Background Lupus nephritis (LN) occurs in more than half of patients with systemic lupus erythematosus, but the cellular and molecular events that contribute to LN are not clearly defined. We reported previously that neutrophil degranulation participates in glomerular injury in mouse models of acute LN. This study tests the hypothesis that glomerular recruitment and subsequent activation of neutrophils result in urine excretion of neutrophil granule constituents that are predictive of glomerular inflammation in proliferative LN. Methods Urine and serum levels of 11 neutrophil granule proteins were measured by antibody-based array in patients with proliferative LN and healthy donors (HDs), and the results were confirmed by ELISA. Glomerular neutrophil accumulation was assessed in biopsies of patients with LN who contributed urine for granule cargo quantitation and normal kidney tissue by microscopy. Degranulation was measured by flow cytometry in neutrophils isolated from patients with LN and HD controls by cell surface granule markers CD63 (azurophilic), CC66b (specific), and CD35 (secretory). Nonparametric statistical analyses were performed and corrected for multiple comparisons. Results Eight granule proteins (myeloperoxidase, neutrophil elastase, azurocidin, olfactomedin-4, lactoferrin, alpha-1-acid glycoprotein 1, matrix metalloproteinase 9, and cathelicidin) were significantly elevated in urine from patients with active proliferative LN by array and/or ELISA, whereas only neutrophil elastase was increased in LN serum. Urine excretion of alpha-1-acid glycoprotein 1 declined in patients who achieved remission. The majority of LN glomeruli contained ≥3 neutrophils. Basal levels of specific granule markers were increased in neutrophils from patients with LN compared with HD controls. Serum from patients with active LN stimulated specific and secretory, but not azurophilic granule, release by HD neutrophils. Conclusions Circulating neutrophils in patients with LN are primed for enhanced degranulation. Glomerular recruitment of those primed neutrophils leads to release and urine excretion of neutrophil granule cargo that serves as a urine marker of active glomerular inflammation in proliferative LN.
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Affiliation(s)
- Nicholas A. Shoctor
- Division of Nephrology and Hypertension, University of Louisville School of Medicine, Louisville, Kentucky
| | - Makayla P. Brady
- Department of Biochemistry and Molecular Genetics, University of Louisville School of Medicine, Louisville, Kentucky
| | - Kenneth R. McLeish
- Division of Nephrology and Hypertension, University of Louisville School of Medicine, Louisville, Kentucky
| | | | | | - Conner Lynn
- University of Louisville School of Medicine, Louisville, Kentucky
| | - Anjali Dubbaka
- Department of Internal Medicine, University of Louisville School of Medicine, Louisville, Kentucky
| | - Shweta Tandon
- Division of Nephrology and Hypertension, University of Louisville School of Medicine, Louisville, Kentucky
| | - Michael W. Daniels
- Department of Bioinformatics and Biostatistics, University of Louisville School of Public Health and Information Sciences, Louisville, Kentucky
| | - Madhavi J. Rane
- Division of Nephrology and Hypertension, University of Louisville School of Medicine, Louisville, Kentucky
- Department of Biochemistry and Molecular Genetics, University of Louisville School of Medicine, Louisville, Kentucky
| | - Michelle T. Barati
- Division of Nephrology and Hypertension, University of Louisville School of Medicine, Louisville, Kentucky
| | - Dawn J. Caster
- Division of Nephrology and Hypertension, University of Louisville School of Medicine, Louisville, Kentucky
| | - David W. Powell
- Division of Nephrology and Hypertension, University of Louisville School of Medicine, Louisville, Kentucky
- Department of Biochemistry and Molecular Genetics, University of Louisville School of Medicine, Louisville, Kentucky
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Chen W, Jin B, Cheng C, Peng H, Zhang X, Tan W, Tang R, Lian X, Diao H, Luo N, Li X, Fan J, Shi J, Yin C, Wang J, Peng S, Yu L, Li J, Wu RQ, Kuang DM, Shi GP, Zhou Y, Wang F, Jiang X. Single-cell profiling reveals kidney CD163 + dendritic cell participation in human lupus nephritis. Ann Rheum Dis 2024; 83:608-623. [PMID: 38290829 DOI: 10.1136/ard-2023-224788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 01/12/2024] [Indexed: 02/01/2024]
Abstract
OBJECTIVES The current work aimed to provide a comprehensive single-cell landscape of lupus nephritis (LN) kidneys, including immune and non-immune cells, identify disease-associated cell populations and unravel their participation within the kidney microenvironment. METHODS Single-cell RNA and T cell receptor sequencing were performed on renal biopsy tissues from 40 patients with LN and 6 healthy donors as controls. Matched peripheral blood samples from seven LN patients were also sequenced. Multiplex immunohistochemical analysis was performed on an independent cohort of 60 patients and validated using flow cytometric characterisation of human kidney tissues and in vitro assays. RESULTS We uncovered a notable enrichment of CD163+ dendritic cells (DC3s) in LN kidneys, which exhibited a positive correlation with the severity of LN. In contrast to their counterparts in blood, DC3s in LN kidney displayed activated and highly proinflammatory phenotype. DC3s showed strong interactions with CD4+ T cells, contributing to intrarenal T cell clonal expansion, activation of CD4+ effector T cell and polarisation towards Th1/Th17. Injured proximal tubular epithelial cells (iPTECs) may orchestrate DC3 activation, adhesion and recruitment within the LN kidneys. In cultures, blood DC3s treated with iPTECs acquired distinct capabilities to polarise Th1/Th17 cells. Remarkably, the enumeration of kidney DC3s might be a potential biomarker for induction treatment response in LN patients. CONCLUSION The intricate interplay involving DC3s, T cells and tubular epithelial cells within kidneys may substantially contribute to LN pathogenesis. The enumeration of renal DC3 holds potential as a valuable stratification feature for guiding LN patient treatment decisions in clinical practice.
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Affiliation(s)
- Wei Chen
- Department of Nephrology, Sun Yat-sen University First Affiliated Hospital, Guangzhou, Guangdong, China
- National Health Commission (NHC), Key Laboratory of Clinical Nephrology (SunYat-Sen University) and Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, Guangdong, China
| | - Bei Jin
- Department of Pediatric Rheumatology and Nephrology, Sun Yat-sen University First Affiliated Hospital, Guangzhou, Guangdong, China
| | - Cheng Cheng
- Department of Pediatric Rheumatology and Nephrology, Sun Yat-sen University First Affiliated Hospital, Guangzhou, Guangdong, China
| | - Huajing Peng
- Department of Nephrology, Sun Yat-sen University First Affiliated Hospital, Guangzhou, Guangdong, China
- National Health Commission (NHC), Key Laboratory of Clinical Nephrology (SunYat-Sen University) and Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, Guangdong, China
| | - Xinxin Zhang
- Department of Nephrology, Sun Yat-sen University First Affiliated Hospital, Guangzhou, Guangdong, China
- National Health Commission (NHC), Key Laboratory of Clinical Nephrology (SunYat-Sen University) and Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, Guangdong, China
| | - Weiping Tan
- Department of Pediatrics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ruihan Tang
- Department of Nephrology, Sun Yat-sen University First Affiliated Hospital, Guangzhou, Guangdong, China
- National Health Commission (NHC), Key Laboratory of Clinical Nephrology (SunYat-Sen University) and Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, Guangdong, China
| | - Xingji Lian
- Department of Nephrology, Sun Yat-sen University First Affiliated Hospital, Guangzhou, Guangdong, China
- National Health Commission (NHC), Key Laboratory of Clinical Nephrology (SunYat-Sen University) and Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, Guangdong, China
| | - Hui Diao
- Department of Nephrology, Sun Yat-sen University First Affiliated Hospital, Guangzhou, Guangdong, China
- National Health Commission (NHC), Key Laboratory of Clinical Nephrology (SunYat-Sen University) and Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, Guangdong, China
| | - Ning Luo
- Department of Nephrology, Sun Yat-sen University First Affiliated Hospital, Guangzhou, Guangdong, China
- National Health Commission (NHC), Key Laboratory of Clinical Nephrology (SunYat-Sen University) and Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, Guangdong, China
| | - Xiaoyan Li
- Department of Nephrology, Sun Yat-sen University First Affiliated Hospital, Guangzhou, Guangdong, China
- National Health Commission (NHC), Key Laboratory of Clinical Nephrology (SunYat-Sen University) and Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, Guangdong, China
| | - Jinjin Fan
- Department of Nephrology, Sun Yat-sen University First Affiliated Hospital, Guangzhou, Guangdong, China
- National Health Commission (NHC), Key Laboratory of Clinical Nephrology (SunYat-Sen University) and Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, Guangdong, China
| | - Jian Shi
- Institute of Precision Medicine, Sun Yat-sen University First Affiliated Hospital, Guangzhou, Guangdong, China
| | - Changjun Yin
- Institute of Precision Medicine, Sun Yat-sen University First Affiliated Hospital, Guangzhou, Guangdong, China
- Institute for Cardiovascular Prevention (IPEK), Ludwig-Maximilians-University, Munich, Germany
| | - Ji Wang
- Institute of Precision Medicine, Sun Yat-sen University First Affiliated Hospital, Guangzhou, Guangdong, China
| | - Sui Peng
- Institute of Precision Medicine, Sun Yat-sen University First Affiliated Hospital, Guangzhou, Guangdong, China
- Clinical Trials Unit, Sun Yat-sen University First Affiliated Hospital, Guangzhou, Guangdong, China
- Department of Gastroenterology and Hepatology, Sun Yat-sen University First Affiliated Hospital, Guangzhou, Guangdong, China
| | - Li Yu
- Department of Pediatrics, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, China
| | - Jun Li
- Organ Transplant Center, Sun Yat-sen University First Affiliated Hospital, Guangzhou, Guangdong, China
| | - Rui-Qi Wu
- Guangdong Province Key Laboratory of Pharmaceutical Functional Genes, MOE Key Laboratory of Gene Function and Regulation, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, and Sun Yat-sen University Cancer Center, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Dong-Ming Kuang
- Guangdong Province Key Laboratory of Pharmaceutical Functional Genes, MOE Key Laboratory of Gene Function and Regulation, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, and Sun Yat-sen University Cancer Center, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Guo-Ping Shi
- Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Yi Zhou
- Department of Nephrology, Sun Yat-sen University First Affiliated Hospital, Guangzhou, Guangdong, China
- National Health Commission (NHC), Key Laboratory of Clinical Nephrology (SunYat-Sen University) and Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, Guangdong, China
| | - Fang Wang
- Institute of Precision Medicine, Sun Yat-sen University First Affiliated Hospital, Guangzhou, Guangdong, China
| | - Xiaoyun Jiang
- Department of Pediatric Rheumatology and Nephrology, Sun Yat-sen University First Affiliated Hospital, Guangzhou, Guangdong, China
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Nachiappa Ganesh R, Graviss EA, Nguyen D, El-Zaatari Z, Gaber L, Barrios R, Truong L, Farris AB. Reproducibility and prognostic ability of chronicity parameters in kidney biopsy - Comprehensive evaluation comparing microscopy and artificial intelligence in digital pathology. Hum Pathol 2024; 146:75-85. [PMID: 38640986 DOI: 10.1016/j.humpath.2024.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 03/26/2024] [Accepted: 04/09/2024] [Indexed: 04/21/2024]
Abstract
INTRODUCTION Semi-quantitative scoring of various parameters in renal biopsy is accepted as an important tool to assess disease activity and prognostication. There are concerns on the impact of interobserver variability in its prognostic utility, generating a need for computerized quantification. METHODS We studied 94 patients with renal biopsies, 45 with native diseases and 49 transplant patients with index biopsies for Polyomavirus nephropathy. Chronicity scores were evaluated using two methods. A standard definition diagram was agreed after international consultation and four renal pathologists scored each parameter in a double-blinded manner. Interstitial fibrosis (IF) score was assessed with five different computerized and AI-based algorithms on trichrome and PAS stains. RESULTS There was strong prognostic correlation with renal function and graft outcome at a median follow-up ranging from 24 to 42 months respectively, independent of moderate concordance for pathologists scores. IF scores with two of the computerized algorithms showed significant correlation with estimated glomerular filtration rate (eGFR) at biopsy but not at the end of follow-up. There was poor concordance for AI based platforms. CONCLUSION Chronicity scores are robust prognostic tools despite interobserver reproducibility. AI-algorithms have absolute precision but are limited by significant variation when different hardware and software algorithms are used for quantification.
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Affiliation(s)
- Rajesh Nachiappa Ganesh
- Department of Pathology and Genomic Medicine, The Houston Methodist Hospital and Research Institute, Houston, TX, USA.
| | - Edward A Graviss
- Department of Pathology and Genomic Medicine, The Houston Methodist Hospital and Research Institute, Houston, TX, USA; J.C. Walter Jr. Transplant Center, Department of Surgery, Houston, TX, USA
| | - Duc Nguyen
- Department of Pediatrics, Baylor College of Medicine, USA.
| | - Ziad El-Zaatari
- Department of Pathology and Genomic Medicine, The Houston Methodist Hospital and Research Institute, Houston, TX, USA
| | - Lillian Gaber
- Department of Pathology and Genomic Medicine, The Houston Methodist Hospital and Research Institute, Houston, TX, USA; J.C. Walter Jr. Transplant Center, Department of Surgery, Houston, TX, USA
| | - Roberto Barrios
- Department of Pathology and Genomic Medicine, The Houston Methodist Hospital and Research Institute, Houston, TX, USA
| | - Luan Truong
- Department of Pathology and Genomic Medicine, The Houston Methodist Hospital and Research Institute, Houston, TX, USA
| | - Alton B Farris
- Department of Pathology and Laboratory Medicine, Emory University Hospital, Atlanta, GA, USA
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Li F, Zhu J, Zheng Y, Fang Y, Hu L, Xiong J. Comparison of bacteremic pneumonia caused by Escherichia coli and Klebsiella pneumoniae: A retrospective study. Saudi Med J 2024; 45:241-251. [PMID: 38438206 PMCID: PMC11115389 DOI: 10.15537/smj.2024.45.3.20230428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 01/15/2024] [Indexed: 03/06/2024] Open
Abstract
OBJECTIVES To compare the prognosis of bacteremic pneumonia caused by Klebsiella pneumoniae (K. pneumoniae) and Escherichia coli (E. coli) pathogens. METHODS A retrospective analysis was carried out on the clinical data of 162 patients who were diagnosed with bacterial pneumonia caused by either K. pneumoniae or E. coli between 2016-2019. The primary outcome of the analysis was the patients' 30-day mortality rate. RESULTS There were 82 patients in the E. coli bacteremic pneumonia (E. coli-BP) group and 80 patients in the K. pneumoniae bacteremic pneumonia (KP-BP) group. The 30-day mortality rate was 43.75% (n=35/80) in the KP-BP group and 21.95% (n=18/82) in the E. coli-BP group (p<0.001). Following the adjustment for confounding variables in 4 distinct models, the hazard ratios for the primary outcome in KP-BP were determined to be 0.70 (95% confidence interval [CI]: [0.44-1.02]) in Model 1, 0.72 (95% CI: [0.46-1.14]) in Model 2, 0.99 (95% CI: [0.57-1.73]) in Model 3, and 1.22 (95% CI: [0.69-2.18]) in Model 4. CONCLUSION Patients diagnosed with KP-BP exhibited a similar prognosis as those diagnosed with E. coli-BP. For patients with KP-BP, the risk of mortality was significantly higher for those who were in the intensive care unit, were infected with carbapenem-resistant strains, or had a high sequential organ failure assessment score. In patients with E. coli-BP, the Pitt bacteremia score was strongly associated with the 30-day mortality rate.
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Affiliation(s)
- Fuxing Li
- From the Second Affiliated Hospital (Li, Zhu, Zheng, Fang, Hu), Jiangxi Medical College, Nanchang University; from the Department of Jiangxi Provincial Key Laboratory of Medicine (Li, Zheng, Hu), Clinical Laboratory of the Second Affiliated Hospital of Nanchang University; and from the Department of Nursing (Xiong), the Second Affiliated Hospital of Nanchang University, Jiangxi, China.
| | - Junqi Zhu
- From the Second Affiliated Hospital (Li, Zhu, Zheng, Fang, Hu), Jiangxi Medical College, Nanchang University; from the Department of Jiangxi Provincial Key Laboratory of Medicine (Li, Zheng, Hu), Clinical Laboratory of the Second Affiliated Hospital of Nanchang University; and from the Department of Nursing (Xiong), the Second Affiliated Hospital of Nanchang University, Jiangxi, China.
| | - Yunwei Zheng
- From the Second Affiliated Hospital (Li, Zhu, Zheng, Fang, Hu), Jiangxi Medical College, Nanchang University; from the Department of Jiangxi Provincial Key Laboratory of Medicine (Li, Zheng, Hu), Clinical Laboratory of the Second Affiliated Hospital of Nanchang University; and from the Department of Nursing (Xiong), the Second Affiliated Hospital of Nanchang University, Jiangxi, China.
| | - Youling Fang
- From the Second Affiliated Hospital (Li, Zhu, Zheng, Fang, Hu), Jiangxi Medical College, Nanchang University; from the Department of Jiangxi Provincial Key Laboratory of Medicine (Li, Zheng, Hu), Clinical Laboratory of the Second Affiliated Hospital of Nanchang University; and from the Department of Nursing (Xiong), the Second Affiliated Hospital of Nanchang University, Jiangxi, China.
| | - Longhua Hu
- From the Second Affiliated Hospital (Li, Zhu, Zheng, Fang, Hu), Jiangxi Medical College, Nanchang University; from the Department of Jiangxi Provincial Key Laboratory of Medicine (Li, Zheng, Hu), Clinical Laboratory of the Second Affiliated Hospital of Nanchang University; and from the Department of Nursing (Xiong), the Second Affiliated Hospital of Nanchang University, Jiangxi, China.
| | - Jianqiu Xiong
- From the Second Affiliated Hospital (Li, Zhu, Zheng, Fang, Hu), Jiangxi Medical College, Nanchang University; from the Department of Jiangxi Provincial Key Laboratory of Medicine (Li, Zheng, Hu), Clinical Laboratory of the Second Affiliated Hospital of Nanchang University; and from the Department of Nursing (Xiong), the Second Affiliated Hospital of Nanchang University, Jiangxi, China.
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Pennesi M, Benvenuto S. Lupus Nephritis in Children: Novel Perspectives. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1841. [PMID: 37893559 PMCID: PMC10607957 DOI: 10.3390/medicina59101841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/10/2023] [Accepted: 10/11/2023] [Indexed: 10/29/2023]
Abstract
Childhood-onset systemic lupus erythematosus is an inflammatory and autoimmune condition characterized by heterogeneous multisystem involvement and a chronic course with unpredictable flares. Kidney involvement, commonly called lupus nephritis, mainly presents with immune complex-mediated glomerulonephritis and is more frequent and severe in adults. Despite a considerable improvement in long-term renal prognosis, children and adolescents with lupus nephritis still experience significant morbidity and mortality. Moreover, current literature often lacks pediatric-specific data, leading clinicians to rely exclusively on adult therapeutic approaches. This review aims to describe pediatric lupus nephritis and provide an overview of the novel perspectives on the pathogenetic mechanisms, histopathological classification, therapeutic approach, novel biomarkers, and follow-up targets in children and adolescents with lupus nephritis.
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Affiliation(s)
- Marco Pennesi
- Institute for Maternal and Child Health IRCCS Burlo Garofolo, 34137 Trieste, Italy
| | - Simone Benvenuto
- Department of Medicine, Surgery, and Health Sciences, University of Trieste, 34127 Trieste, Italy
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6
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Barr B, Harasemiw O, Gibson IW, Tremblay-Savard O, Tangri N. The Development of a Comprehensive Clinicopathologic Registry for Glomerular Diseases Using Natural Language Processing. Can J Kidney Health Dis 2023; 10:20543581231178963. [PMID: 37342151 PMCID: PMC10278432 DOI: 10.1177/20543581231178963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 04/22/2023] [Indexed: 06/22/2023] Open
Abstract
Background Glomerulonephritis (GN) represents a common cause of chronic kidney disease, and treatment to slow or prevent progression of GN is associated with significant morbidity. Large patient registries have improved the understanding of risk stratification, treatment selection, and definitions of treatment response in GN, but can be resource-intensive, with incomplete patient capture. Objective To describe the creation of a comprehensive clinicopathologic registry for all patients undergoing kidney biopsy in Manitoba, using natural language processing software for data extraction from pathology reports, as well as to describe cohort characteristics and outcomes. Design Retrospective population-based cohort study. Setting Tertiary care center in the province of Manitoba. Patients All patients undergoing a kidney biopsy in the province of Manitoba from 2002 to 2019. Measurements Descriptive statistics are presented for the most common glomerular diseases, along with outcomes of kidney failure and mortality for the individual diseases. Methods Data from native kidney biopsy reports from January 2002 to December 2019 were extracted into a structured database using a natural language processing algorithm employing regular expressions. The pathology database was then linked with population-level clinical, laboratory, and medication data, creating a comprehensive clinicopathologic registry. Kaplan-Meier curves and Cox models were constructed to assess the relationship between type of GN and outcomes of kidney failure and mortality. Results Of 2421 available biopsies, 2103 individuals were linked to administrative data, of which 1292 had a common glomerular disease. The incidence of yearly biopsies increased almost 3-fold over the study period. Among common glomerular diseases, immunoglobulin A (IgA) nephropathy was the most common (28.6%), whereas infection-related GN had the highest proportions of kidney failure (70.3%) and all-cause mortality (42.3%). Predictors of kidney failure included urine albumin-to-creatinine ratio at the time of biopsy (adjusted hazard ratio [HR] = 1.43, 95% confidence interval [CI] = 1.24-1.65), whereas predictors of mortality included age at the time of biopsy (adjusted HR = 1.05, 95% CI = 1.04-1.06) and infection-related GN (adjusted HR = 1.85, 95% CI = 1.14-2.99, compared with the reference category of IgA nephropathy). Limitations Retrospective, single-center study with a relatively small number of biopsies. Conclusions Creation of a comprehensive glomerular diseases registry is feasible and can be facilitated through the use of novel data extraction methods. This registry will facilitate further epidemiological research in GN.
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Affiliation(s)
- Bryce Barr
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, MB, Canada
| | - Oksana Harasemiw
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, MB, Canada
| | - Ian W Gibson
- Department of Pathology, University of Manitoba, Winnipeg, Canada
- Shared Health Services Manitoba, Winnipeg, Canada
| | | | - Navdeep Tangri
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, MB, Canada
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Bajema IM, Balow JE, Haas M, Jayne D, Lightstone L, Rovin BH, Seshan SV, Fogo AB. Update on scoring and providing evidence basis for assessing pathology in lupus nephritis. Kidney Int 2023; 103:813-816. [PMID: 37085251 DOI: 10.1016/j.kint.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 01/16/2023] [Accepted: 02/07/2023] [Indexed: 04/23/2023]
Affiliation(s)
- Ingeborg M Bajema
- Department of Pathology and Medical Biology, University of Groningen, University Medical Center, Groningen, The Netherlands; Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands.
| | - James E Balow
- Kidney Disease Section, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland, USA
| | - Mark Haas
- Department of Pathology & Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - David Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Liz Lightstone
- Faculty of Medicine, Imperial College London, London, UK
| | - Brad H Rovin
- Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA; Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Surya V Seshan
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York, USA
| | - Agnes B Fogo
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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8
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Lim SC, Chan EWL, Mandal SS, Tang SP. A Preliminary Predictive Model for Proliferative Lupus Nephritis in Juvenile Systemic Lupus Erythematosus. RHEUMATO 2023; 3:86-97. [DOI: 10.3390/rheumato3010007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/19/2023]
Abstract
Proliferative lupus nephritis, which is diagnosed by renal biopsy, has significant impact on the treatment choices and long-term prognosis of juvenile SLE (jSLE). Renal biopsies are however not always possible or available, thus leading to an ongoing search for alternative biomarkers. This study aimed to develop a clinical predictive machine learning model using routine standard parameters as an alternative tool to evaluate the probability of proliferative lupus nephritis (ISN/RPS Class III or IV). Data were collected retrospectively from jSLE patients seen at Selayang Hospital from 2004 to 2021. A total of 22 variables including demographic, clinical and laboratory features were analyzed. A recursive feature elimination technique was used to identify factors to predict pediatric proliferative lupus nephritis. Various models were then used to build predictive machine learning models and assessed for sensitivity, specificity and accuracy. There were 194 jSLE patients (165 females), of which 111 had lupus nephritis (54 proliferative pattern). A combination of 11 variables consisting of gender, ethnicity, fever, nephrotic state, hypertension, urine red blood cells (RBC), C3, C4, duration of illness, serum albumin, and proteinuria demonstrated the highest accuracy of 79.4% in predicting proliferative lupus nephritis. A decision-tree model performed the best with an AROC of 69.9%, accuracy of 73.85%, sensitivity of 78.72% and specificity of 61.11%. A potential clinically useful predictive model using a combination of 11 non-invasive variables to collectively predict pediatric proliferative lupus nephritis in daily practice was developed.
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Affiliation(s)
- Sern Chin Lim
- Department of Paediatrics, Faculty of Medicine, Universiti Teknologi MARA (UiTM), Sungai Buloh 47000, Malaysia
| | - Elaine Wan Ling Chan
- Institute for Research, Development and Innovation, International Medical University, Bukit Jalil, Kuala Lumpur 57000, Malaysia
| | | | - Swee Ping Tang
- Paediatric Rheumatology Unit, Selayang Hospital, Batu Caves 68100, Malaysia
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9
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Patel P, de Guzman M, Hicks MJ, Maliakkal JG, Rheault MN, Selewski DT, Twombley K, Misurac JM, Tran CL, Constantinescu AR, Onder AM, Seamon M, Seeherunvong W, Singh V, Pan C, Okamura DM, Omoloja A, Kallash M, Smoyer WE, Hidalgo G, Wenderfer SE. Utility of the 2018 revised ISN/RPS thresholds for glomerular crescents in childhood-onset lupus nephritis: a Pediatric Nephrology Research Consortium study. Pediatr Nephrol 2022; 37:3139-3145. [PMID: 35347402 DOI: 10.1007/s00467-022-05524-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 02/21/2022] [Accepted: 03/01/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND The revised 2018 ISN/RPS Classification System for lupus nephritis (LN) includes calculations for both activity index (A.I.) and chronicity index (C.I.). Unchanged were the thresholds of < 25%, 25-50%, and > 50% crescents to distinguish between mild, moderate, and severe activity/chronicity. We aimed to evaluate these thresholds for percent crescents in childhood-onset LN. METHODS Eighty-six subjects < 21 years of age were enrolled from the Pediatric Glomerulonephritis with Crescents Registry, a retrospective multi-center cohort sponsored by the Pediatric Nephrology Research Consortium. Thresholds of 10%, 25%, and 50% for both cellular/fibrocellular and fibrous crescents were interrogated for primary outcomes of kidney failure, eGFR, and eGFR slope. RESULTS Median age at time of initial biopsy was 14 years (range 1-21). Median follow-up time was 3 years (range 1-11). Cumulative incidence of kidney failure was 6% at 1 year and 10% at latest follow-up. Median eGFR slope was - 18 mL/1.73 m2/min (IQR - 51 to + 8) at 1 year and - 3 mL/min/1.73 m2/year (IQR - 19 to + 6) at latest follow-up. We found no difference in kidney failure at the proposed < 25% and 25-50% cellular crescents thresholds, and thus added a new provisional threshold of 10% that better predicted outcomes in children. Moreover, use of 10% and 25% thresholds for fibrous crescents showed a fourfold and sevenfold increase in risk of kidney failure. CONCLUSIONS In children with crescentic LN, use of 10% and 25% thresholds for cellular crescents better reflects disease activity, while these thresholds for fibrous crescents better discriminates kidney disease outcomes. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Pooja Patel
- Pediatric Rheumatology, Texas Children's Hospital, TX, Houston, USA.,Baylor College of Medicine, Houston, TX, USA.,Pediatric Rheumatology, Northwestern University, Chicago, IL, USA
| | - Marietta de Guzman
- Pediatric Rheumatology, Texas Children's Hospital, TX, Houston, USA.,Baylor College of Medicine, Houston, TX, USA
| | - M John Hicks
- Baylor College of Medicine, Houston, TX, USA.,Pathology, Texas Children's Hospital, Houston, TX, USA
| | | | | | - David T Selewski
- Pediatric Nephrology, Medical University of South Carolina, Charleston, SC, USA
| | - Katherine Twombley
- Pediatric Nephrology, Medical University of South Carolina, Charleston, SC, USA
| | - Jason M Misurac
- Pediatric Nephrology, University of Iowa, Iowa City, IA, USA
| | - Cheryl L Tran
- Pediatric Nephrology, Mayo Clinic, Rochester, MN, USA
| | | | - Ali M Onder
- Pediatric Nephrology, University of Mississippi, Jackson, MS, USA
| | - Meredith Seamon
- Pediatric Nephrology, University of Utah, Salt Lake City, UT, USA
| | | | - Vaishali Singh
- Pediatric Nephrology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Cynthia Pan
- Pediatric Nephrology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Daryl M Okamura
- Pediatric Nephrology, University of Washington, Seattle Children's Hospital, Seattle, WA, USA
| | - Abiodun Omoloja
- Pediatric Nephrology, Wright State University, Dayton, OH, USA
| | - Mahmoud Kallash
- Pediatric Nephrology, Nationwide Children's Hospital, Columbus, OH, USA
| | - William E Smoyer
- Pediatric Nephrology, Nationwide Children's Hospital, Columbus, OH, USA
| | | | - Scott E Wenderfer
- Baylor College of Medicine, Houston, TX, USA. .,Pediatric Nephrology, Texas Children's Hospital, Houston, TX, USA.
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10
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Moroni G, Calatroni M, Ponticelli C. Severe lupus nephritis in the present days. FRONTIERS IN NEPHROLOGY 2022; 2:984613. [PMID: 37675028 PMCID: PMC10479763 DOI: 10.3389/fneph.2022.984613] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 07/22/2022] [Indexed: 09/08/2023]
Abstract
Lupus nephritis (LN) is one of the most frequent and severe organ manifestations of systemic lupus erythematosus (SLE) that is a chronic autoimmune disease. Despite improvement in patient and renal prognosis, the disease continued to be associated with a high rate of end stage kidney disease. Along the last decades, it seems that the epidemiology of LN and its clinical presentation have progressively changed. The forms with renal insufficiency at presentation seem to have progressively reduced in developed countries in favour of more mild clinical presentations with urinary abnormalities only. To this clinical change does not correspond a less severe histological lesions, in fact, the extent of active lesions at kidney biopsy are unchanged, whereas chronic lesions are becoming less frequent and less severe. Meanwhile, new types of severe LN defined by the variable association of demographic, clinical, histological characteristics at diagnosis or during the follow-up are gradually emerging and require attention in assessing the therapy and prognosis. During the last years, randomized controlled trials have reported the efficacy of new drugs in association with standard therapy to improve the rate of short- and medium-term renal response. One of the advantages is that these results were obtained with reduced dosage of corticosteroids whose protracted use is associated with increase of chronic organ damage. Optimization of therapeutical strategies, tailored on the demographic clinical and histological characteristics, with combination of old and new drugs are urgently needed for severe LN.
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Affiliation(s)
- Gabriella Moroni
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele Milan, Italy
- Nephrology and Dialysis Division, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Humanitas Research Hospital, Milan, Italy
| | - Marta Calatroni
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele Milan, Italy
- Nephrology and Dialysis Division, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Humanitas Research Hospital, Milan, Italy
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11
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Porta SV, Enfrein A, Houssiau F, García M, Furie R, Rovin BH, Alarcón GS, Pons-Estel BA, Pons-Estel GJ. Controversies in Systemic Lupus Erythematosus 2021: Changing the Paradigm in the Management of Lupus Nephritis. J Clin Rheumatol 2022; 28:229-233. [PMID: 35616510 DOI: 10.1097/rhu.0000000000001859] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
ABSTRACT Lupus nephritis (LN) affects about a third of patients with systemic lupus erythematosus. Although the use of conventional therapy has significantly improved the prognosis of LN, the response to treatment remains suboptimal, with high rates of relapse and the occurrence of end-stage kidney disease. The implementation of new diagnostic and treatment strategies aimed at improving these outcomes represents a necessary paradigm shift in the management of LN.Herein, we discuss different points of view regarding these still unresolved issues; these comments represent a debate that took place during the virtual congress of the Pan American League of Associations for Rheumatology (PANLAR) and which was organized by the PANLAR Lupus Study Group, GLADEL (Grupo Latino Americano De Estudio del Lupus) on August 15, 2021.
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Affiliation(s)
- Sabrina Valeria Porta
- From the Rheumatology Department, Carlos G. Durand Hospital, Buenos Aires, Argentina
| | - Antoine Enfrein
- Internal Medicine Department, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | | | - Mercedes García
- Rheumatology Department, Hospital Interzonal General de Agudos San Martin de La Plata, La Plata, Argentina
| | - Richard Furie
- Division of Rheumatology, Northwell Health, Great Neck, NY
| | - Brad H Rovin
- Division of Nephrology, Ohio State University Wexner Medical Center, Columbus, OH
| | | | - Bernardo A Pons-Estel
- Centro Regional de Enfermedades Autoinmunes y Reumáticas (GO-CREAR), Rosario, Argentina
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12
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Shater H, Fawzy M, Farid A, El-Amir A, Fouad S, Madbouly N. The potential use of serum interleukin-21 as biomarker for lupus nephritis activity compared to cytokines of the tumor necrosis factor (TNF) family. Lupus 2022; 31:55-64. [PMID: 34978958 DOI: 10.1177/09612033211063794] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Lupus nephritis (LN) is a significant consequence of systemic lupus erythematosus (SLE). To the best of our knowledge, this is the first work that focuses on evaluation of serum interleukin (IL-) 21 as a diagnostic biomarker of LN activity, compared to B lymphocyte stimulator (BlyS), tumor necrosis factor ligand superfamily member 13 (TNF-SF13), and traditional techniques of active LN attempting to compare their diagnostic usefulness. METHODS Serum levels of IL-21, BlyS, and TNF-SF13 during LN were investigated. Twenty-five biopsy-proven, active LN female patients and 15 SLE patients without active LN and 20 healthy controls (HCs) joined this work. RESULTS Serum IL-21 level was significantly higher in active LN group than in inactive LN group. Correlation analysis showed that serum IL-21 levels were significantly correlated with total SLEDAI (r = 0.41, p = 0.03), renal-SLEDAI (r = 0.48, p = 0.04), renal activity index (AI) (r = 0.93; p < 0.001), and 24-h proteinuria (r = 0.51; p > 0.008). Receiver operating characteristic curve (ROC) revealed the ability of serum IL-21 to discriminate between active and inactive LN with 70% sensitivity at >240 pg/ml cutoff point (AUC 0.809). CONCLUSION For Egyptian SLE patients, serum levels of IL-21 were superior to TNF-SF13 and BlyS and correlated significantly with the activity indexes of LN, indicating a promising role as a potential biomarker of active LN.
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Affiliation(s)
- Hend Shater
- Zoology Department, Faculty of Science, Cairo University, Cairo, Egypt
| | - Mary Fawzy
- Department of Internal Medicine, Faculty of Medicine (Kasr Al-Ainy School of Medicine), 98876Cairo University, Cairo, Egypt
| | - Alyaa Farid
- Zoology Department, Faculty of Science, Cairo University, Cairo, Egypt
| | - Azza El-Amir
- Zoology Department, Faculty of Science, Cairo University, Cairo, Egypt
| | - Salwa Fouad
- Zoology Department, Faculty of Science, Cairo University, Cairo, Egypt
| | - Neveen Madbouly
- Zoology Department, Faculty of Science, Cairo University, Cairo, Egypt
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13
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Moroni G, Porata G, Raffiotta F, Quaglini S, Frontini G, Sacchi L, Binda V, Calatroni M, Reggiani F, Banfi G, Ponticelli C. Beyond ISN/RPS Lupus Nephritis Classification: Adding Chronicity Index to Clinical Variables Predicts Kidney Survival. KIDNEY360 2021; 3:122-132. [PMID: 35368572 PMCID: PMC8967609 DOI: 10.34067/kid.0005512021] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 11/01/2021] [Indexed: 01/10/2023]
Abstract
Background A renewed interest for activity and chronicity indices as predictors of lupus nephritis (LN) outcome has emerged. Revised National Institutes of Health activity and chronicity indices have been proposed to classify LN lesions, but they should be validated by future studies. The aims of this study were (1) to detect the histologic features associated with the development of kidney function impairment (KFI), and (2) to identify the best clinical-histologic model to predict KFI at time of kidney biopsy. Methods Patients with LN who had more than ten glomeruli per kidney biopsy specimen were admitted to the study. Univariate and multivariate logistic regression and Cox proportional hazards models were used to investigate whether activity and chronicity indices could predict KFI development. Results Among 203 participants with LN followed for 14 years, correlations were found between the activity index, and its components, and clinical-laboratory signs of active LN at baseline. The chronicity index was correlated with serum creatinine. Thus, serum creatinine was significantly and directly correlated with both activity and chronicity indices. In the multivariate analysis, glomerulosclerosis (OR, 3.05; 95% CI, 1.17 to 7.91; P=0.02) and fibrous crescents (OR, 6.84; 95% CI, 3.22 to 14.52; P<0.001) associated with either moderate/severe tubular atrophy (OR, 3.17; 95% CI, 1.04 to 9.64; P=0.04), or with interstitial fibrosis (OR, 2.36; 95% CI, 1.05 to 5.32; P=0.04), predicted KFI. Considering both clinical and histologic features, serum creatinine (OR, 1.68; 95% CI, 1.31 to 2.15; P<0.001), arterial hypertension (OR, 4.64; 95% CI, 1.90 to 11.32; P<0.001), glomerulosclerosis (OR, 2.12; 95% CI, 1.00 to 4.50; P=0.05), and fibrous crescents (OR, 5.18; 95% CI, 2.43 to 11.04; P<0.001) independently predicted KFI. Older age (P<0.001) and longer delay between clinical onset of LN and kidney biopsy (P<0.001) were significantly correlated with baseline chronicity index. Conclusions The chronicity index and its components, but not the activity index, were significantly associated with an impairment of kidney function. The Cox model showed that serum creatinine, arterial hypertension, chronic glomerular lesions, and delay in kidney biopsy predicted KFI. These data reinforce the importance of timely kidney biopsy in LN.
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Affiliation(s)
- Gabriella Moroni
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Giulia Porata
- Nephrology and Dialysis Unit, San Paolo Hospital, Milan, Italy
| | | | - Silvana Quaglini
- Department of Electrical, Computer and Biomedical Engineering, University of Pavia, Pavia, Italy
| | - Giulia Frontini
- Nephrology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Lucia Sacchi
- Department of Electrical, Computer and Biomedical Engineering, University of Pavia, Pavia, Italy
| | - Valentina Binda
- Nephrology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Marta Calatroni
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
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14
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Worawichawong S, Plumworasawat S, Liwlompaisan W, Sumethkul V, Phakdeekitcharoen B, Udomsubpayakul U, Chalermsanyakorn P, Kitiyakara C. Distribution pattern of mesangial C4d deposits as predictor of kidney failure in IgA nephropathy. PLoS One 2021; 16:e0252638. [PMID: 34081719 PMCID: PMC8174712 DOI: 10.1371/journal.pone.0252638] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 05/20/2021] [Indexed: 02/05/2023] Open
Abstract
Mesangial C4d deposits have been associated with worse outcomes in Western patients with IgA nephropathy (IgAN), but there is limited data in Asians. Previously, a high proportion of stained glomeruli was often required for the classification of C4d positive (C4d+ve). Positive staining in lower proportion of staining would be classified as C4d-ve. This retrospective study evaluated the prognostic value of C4d+ve using a less stringent definition (one C4d+ve glomerulus) in Thai patients with IgAN (n = 120). Baseline findings and outcomes were compared between those with more extensive C4d staining patterns and those with more restricted staining. Clinico-pathologic parameters and risk for kidney outcomes (kidney failure or decline GFR50%) were compared between C4d+ve versus C4d-ve, and between different patterns: Focal (< 50%) versus Diffuse (≥ 50% of glomeruli); or Global (≥ 50) versus Segmental (< 50% of mesangial area). The hazard ratios were estimated using Cox proportional hazard models for Model 1 (Oxford score+ C4d) and Model 2 (Model 1+ clinical factors). C4d+ve (n = 81) had lower eGFR, more global sclerosis, and interstitial fibrosis than C4d-ve at baseline. The 5-year kidney survival for C4d+ve was lower (53.7%) than C4d-ve (89.7%); P = 0.0255. By univariate analysis, T1, T2, C4d+ve, eGFR<60, proteinuria were predictors of kidney outcome. By multivariate analysis, proteinuria, T1, T2 and C4d+ve were independent predictors (Model 2 HR (95% CI) C4d+ve: 3.24 (1.09-9.58), p = 0.034). Segmental had lower eGFR, higher tubulointerstitial fibrosis, and segmental sclerosis compared to Global pattern. Clinicopathological parameters were not different between Focal and Diffuse patterns. Outcomes were similar between staining patterns. In conclusion, C4d staining may be a valuable marker of poor prognosis in Asian patients with IgAN. Less stringent criteria for C4d+ve should be considered as no differences in outcomes were observed between more extensive staining with less extensive patterns. More studies are needed to identify the optimum criteria for C4d+ve.
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Affiliation(s)
- Suchin Worawichawong
- Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sirithep Plumworasawat
- Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Wisit Liwlompaisan
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Vasant Sumethkul
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Bunyong Phakdeekitcharoen
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Umaporn Udomsubpayakul
- Section for Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Panus Chalermsanyakorn
- Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chagriya Kitiyakara
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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